<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Managing an Effective Safety Committee
Thomas A Zahorsky, CHSP, CHFM
Co-presented by William A Johnson, CHFM
Prepared for the American Society of Hospital Engineering
2008 Annual Conference and Exhibition
Washington, D.C.
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Table of Contents
Introduction .................................................................................................................................................. 3
The Challenge ............................................................................................................................................... 3
An Effective Committee - Definition ........................................................................................................... 3
An Effective Committee – Essential Attributes ......................................................................................... 3
Leadership Involvement and Administrative Support.............................................................................. 4
Management of Information........................................................................................................................ 5
Chart 1: Information Collection and Evaluation System ........................................................................... 6
A Structured Meeting Process ..................................................................................................................... 7
Problem Identification and Evaluation Process......................................................................................... 8
Performance Indicators ............................................................................................................................. 8
Chart 2: Sample Performance Indicators .................................................................................................. 9
Incident Reports ....................................................................................................................................... 10
Root Cause Analysis ................................................................................................................................ 10
An in-depth discussion of the RCA process would take a paper unto itself, but it can be summarized
as follows: .................................................................................................................................................... 10
Effective Communications ......................................................................................................................... 10
Minutes .................................................................................................................................................... 10
Action Plans and Reminders .................................................................................................................... 11
Leadership Report ................................................................................................................................... 11
Measuring the Impact ................................................................................................................................ 11
Effective Use of the Annual Evaluation Process ...................................................................................... 12
Conclusion ................................................................................................................................................... 12
Attachments: ............................................................................................................................................... 12
Sample Safety Committee Agenda ..................................................................................................... 12
Sample Report to Leadership .............................................................................................................. 12
Sample Safety Committee Minutes..................................................................................................... 12
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Managing an Effective Safety Committee
Thomas A Zahorsky, CHSP, CHFM
Introduction
The Safety Committee is a multi-disciplinary group that is charged with the responsibility
of driving improvement in the level of safety in their organization. Typically, this is a
highly educated group of natural leaders with expertise in clinical or other areas but no
particular training in safety management. Organizing these varied personalities into a
functional, cohesive group that has an impact on safety in the organization can be a
challenge. This paper presents a typical process that if followed, will increase the
likelihood of a committee that directs the safety program in a manner that results in
positive change.
The Challenge
Many Safety Committees meet primarily because someone told them that they have to.
Without a clear understanding of purpose and process, these groups do their best to meet
“requirements” by collecting and reporting data that they believe will satisfy regulatory
requirements or accrediting body standards. In many cases, this is what the committee
believes that it is to do.
Without a true understanding of the purpose for, and successful processes employed by
an effective safety committee, these groups often fall short of ever really achieving an
impact on the level of safety in their organization.
An Effective Committee - Definition
To define what it means to have an effective safety committee, consider the impact that
the group has on the organization’s culture. Does the committee cause change? If
nothing changes within the hospital as a result of the recommendations and actions of the
Safety Committee, then it is not an effective group. To be effective the committee must
have a number of attributes in place.
An Effective Committee – Essential Attributes
Safety Committee members are not safety professionals. They all have other jobs that
they were most likely highly educated for, but safety is usually not one of them.
Committee members may think that they sit on the committee because someone told
them that they have to but in reality, they were likely chosen because the represent a part
of the hospital’s operations that carries potential for safety program improvement. The
very best safety committees consist of truly engaged members with a passion for safety.
In most cases, this has to be developed through training, education and a bit of marketing.
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
While this may seem a daunting prospect, it can be done once this group is shown how.
In order to accomplish things with the safety committee, the following are essential.
¾
¾
¾
¾
¾
¾
¾
¾
Leadership Involvement and Administrative Support
Management of Information
A Structured Meeting Process
Problem Identification and Evaluation Process
The Development of Recommendations for Change
Effective Communications of Recommendations
Effective Means of Measuring Improvement
Effective Use of the Annual Evaluation Process
Leadership Involvement and Administrative Support
Any program that can have an impact on the culture of the organization must be
supported at the very top. Safety Management is a process that involves everyone in the
hospital and absolutely requires Governing Body and Administrative Support. The Joint
Commission leadership standards speak to hospital leadership’s responsibilities in several
ways. LD 4.60 speaks to leadership’s responsibility for patient safety and LD 4.70
requires that leadership measures and assesses safety improvement activities. LD 3.60
holds leadership accountable for assuring effective communications in their organization.
Leadership, by these standards, includes Administration and the Governing Body.
In addition to these requirements The Joint Commission standard EC.9.20 requires a
multi-disciplinary process including a performance improvement team that meets not less
that bi-monthly that includes representation from Administration. From a practical
standpoint, the committee must have the ability to approve action plans that may require
expense, and a member of Administration on the team is essential to making things
happen in a timely manner.
Members of the committee should be chosen partially for their role in leading or working
in problematic areas of the hospital or areas where improvement in safety is called for.
Additionally, members should be included that can bring measurement capability and the
ability to help implement change as called for by committee. At a minimum, the
information identified above must come to committee regularly. Therefore, members
should be chosen that can provide the necessary information to the committee in a
meaningful manner.
Small committees are generally more effective than larger ones. A group of ten to twelve
engaged members will give multi-disciplinary perceptions of issues before the committee
but still be manageable and dynamic. Committees of twenty or more members tend to be
cumbersome to work with and may prove unable to reach conclusions in a timely
manner. The larger the group, the more likely that consensus will be difficult to reach.
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Leadership should not only appoint committee members, but should impart an
understanding of the importance of their role and give clear guidance on how their
involvement can impact safety in their area of responsibility. The ICU Director, for
example, likely faces issues with lower back injuries among the ICU staff. Involvement
in the Safety Program will provide this leader with a means of causing improvement that
directly affects the staff and patients in the ICU. There are many such examples. By
focusing each of the committee members on areas that are problematic for them, yet have
a potential impact on the entire organization, a Safety Committee of engaged leaders and
employees can be assembled.
Convening meetings as scheduled and having a high level of regular attendance on the
part of all members is also essential. Here, Hospital Leadership can play a role as well.
The traditional method is one of accountability. Attendance records reported to
Administration is one means of assuring “compliance” with attendance requirements.
However, a more positive approach is likely to be more effective. By instilling as sense
of value in the committee members as described above, committee members will want to
attend meetings as they will know that by doing so, they can cause positive change in
their area and the hospital as a whole.
Management of Information
The Safety Officer’s Information Collection and Evaluation System (ICES) is a process
through which information relative to the following is routed to Safety Committee. The
Joint Commission requires that the following issues be addressed by a multi-disciplinary
performance improvement team, usually referred to as the Safety Committee. The Joint
Commission standard EC.9.10 requires processes for reporting and investigation of:
Injuries to patients or others coming to the hospital's facilities as well as incidents
of property damage
Occupational illnesses and injuries to staff
Security incidents involving patients, staff, or others coming to the hospital's
facilities or property
Hazardous materials and waste spills, exposures, and other related incidents
Fire-safety management problems, deficiencies, and failures
Equipment-management problems, failures, and user errors
Utility systems management problems, failures, or user errors
In addition, the committee should have routine monitors of performance improvement
indicators for each of the seven disciplines of the EOC®. These may include the above
or involve other issues, but should be relevant to recognized needs for improvement
within the organization. This information must be available to the committee at each
meeting. The following chart provides a graphical view of a typical ICES or Information
Collection and Evaluation System.
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Chart 1: Information Collection and Evaluation System
Sample Medical Center
Information Collection and Evaluation System
(ICES)
Adminstration
and Dept. Dirs
Staff Updates
Action Plans
Safety Committee
Chair Report to
Leadership
Committee
Recomendations
Others Assigned
Action Plans
Feedback on
Implementation
Safety Committee
Collects and
Evaluates Data
Safety Management
Patient Safety
Employee Safety
Hazard Surviellance
Product Recalls
Emergency
Management
HVA, Plans
Drills, Events, Critiques
Equipment & Supplies
Security Management
Security Incidents
Performance Indicators
Security Drills
Hazmat & Waste
Management
Spills/Incidents
MSDS Maintenance
Right To Know
Life Safety
Management
Fire Drills
BMP
Fire Safety Equipment
Medical Equipment
Management
Bio-Medical
Diagnositc Imaging
Utility Management
Utility Incidents
Performance Indicators
Infection Control
Education
Staff Knowledge
and Training in All
Areas
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
A Structured Meeting Process
An agenda that provides a clear outline for the flow of the Safety Committee meeting is
one of the simplest, yet most effective steps that can be taken to guide the committee
through the necessary process. Without a well-written agenda, the committee’s meetings
will ramble and may accomplish little. Key components of this agenda include:
Education of Committee Members
Old Business
Performance Indicators for each of the Seven Disciplines
Reports of incidents
New Business
The order of these items is critical. Keeping in mind that the Safety Committee members
are not safety management professionals, it is essential that they be provided regular
education in safety and Environment of Care® issues. Newsletter articles, summaries of
seminars attended by the Safety Officer or other subject matter expert and best practices
from other facilities can all serves as sources of information for a 10 minute education
session at the beginning of each meeting. This process promotes continuous
improvement in the committee itself.
Old Business consists of any action items from the previous meeting that was not closed
in that meeting. These are identified in the minutes of the previous meeting and must be
on the agenda for the next meeting(s) until completed, else they just get lost. Here is
where many Safety Committees fail. Tracking Old Business is essential to assuring
completion of actions called for in previous meetings. A failure to do this effectively will
eventually degrade the effectiveness of the committee and along with that, the desire to
be a part of that team. Involvement supports effectiveness and vice-versa. Without a
feeling of accomplishment, members will lose enthusiasm for their roles and they will
become frustrated by a lack of accomplishment by the committee. When the committee
sees the results of their efforts in the form of accomplished improvements, they will see
the value of their involvement and be inspired to remain actively involved in the
committee and related activities.
Performance indicators for each of the seven disciplines should be called for on the
standing agenda next. Without a requirement for the review of the performance
indicators at each meeting, the focus of the committee can wander and the committee
may end up reviewing old information. The review, evaluation and development of
recommendations and action plans based on the performance indicators are how the
committee does its real job. Completing this process regularly is in no small part what
causes the committee to be effective.
Reporting and investigating incidents of those items identified in Part 2 is also essential.
The most common breakdown here is that many Safety Committees stop at the reporting
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
stage and fall short of completing the investigation part. The investigation can be formal
or informal and can be done by committee or a person designated for focus in a particular
area, but should work to identify the root cause of the event. Beyond that, once
investigation determines the underlying or root cause of the incident, the committee must
make recommendations for change that will have an impact. This becomes an action
plan with a person assigned responsibility and a deadline for accomplishment and then is
tracked as an Old Business item for follow up at the next meeting.
New Business in this context are items that Safety Committee members bring to the
committee for discussion. This does not include Performance Indicators or incident and
accident reports. New Business in this case are ideas, complaints and other issues that do
not fit into the standing agenda at any other point. Saving this type of New Business until
last helps assure that individual members do not “take over” the meeting with their
personal agenda. By saving New Business until the end, and the time spent on these
issues will be minimized as the members will be ready to end the meeting by the time
these items are placed on the table for discussion. This process will also better assure
that Old Business and Performance Indicators are addressed before the group runs out of
time or energy. Please refer to the sample agenda in the attachments.
Problem Identification and Evaluation Process
This takes place in the Safety Committee meeting. The meetings of the Safety
Committee are where the information gathered is to be used to analyze conditions in the
hospital relative to safety. By evaluating the information gathered through the ICES, the
committee can come to conclusions as to what caused undesired outcomes, incidents and
other potentially avoidable events.
Performance Indicators
For each of the major areas of consideration, often called the disciplines of the
Environment of Care®, there should be performance indicators that measure the
effectiveness of the Safety Program in the hospital. Performance indicators should be
used to measure the impact of organizational or process changes that the committee has
recommended in the past. These should focus on key problem areas, or areas where
improvement is called for.
Performance indicators are usually determined through the annual evaluation process but
can also be put into place at any time based on conclusions and recommendations by the
safety committee. For example, if the committee repeatedly hears reports of
undocumented security incidents as a result of failures of the security video surveillance
system, the committee may consider a recommendation to create a monitor, or
performance indicator to report how many cameras, or what percent of the entire system
is found to be functional during periodic inspections. There is no need wait until the
annual evaluation process takes place to implement a performance indicator that will help
drive improvement.
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Chart 2: Sample Performance Indicators
Safety Management
Monitor the knowledge of employees in the safety components of annual re-training. Test
scores from each of the EOC Categories are at least 95% taken by random sampling.
¾ Safety Management
¾ Employee Safety Management
¾ Security Management
¾ Emergency Management
¾ Hazardous Materials and Waste Management
¾ Life Safety Management
¾ Medical Equipment Management
¾ Utilities Management
National Patient Safety Goal Compliance Rate
Inpatient Fall Rate (falls/1000 patient days)
Employee Safety – Lost Time Injury Rate is Below State Average for SIC Code
Employee Safety – Needle stick or other injury rate below prior year (per 100,000 worked hours)
Hazard Surveillance – percent of probes found to be in compliance
Product Recalls – percent of recalls and notices responded to by deadlines
Security Management
Security Incidents per month by type
Security - % of CCTV system operational monthly
Security – staff scores on security drills
Security – response time to events of different types
Security – number of incidents of different types compared to year prior
Emergency Management
Emergency Preparedness scored staff performance on drills
Percent of HRSA Grant Funded Supplies Locatable
Percent of Emergency Contacts Valid During Random Test Calls (after hours)
Hazardous Materials and Waste Management
Hazardous Materials % accuracy of MSDS books random sample
Hazardous Materials & Waste – lbs. Infectious waste/patient day prior year comparison
Fire Prevention and Life Safety
Life Safety – staff score at least 95% on fire drill performance
Life Safety – all staff participate each year
Life Safety – BMP compliance rates > 95%
Medical Equipment Management
Medical Equipment Management – percent PM completed monthly
Medical Equipment Management – percent repairs completed (m)
Medical Equipment Management – average turn around time
Medical Equipment Management – User Error Rate as % of reported equip. failures
Utilities Management
Utilities Management – percent PM completed monthly
Utilities Management – percent repairs completed monthly
Utilities Management – average response time
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
Incident Reports
In addition to reviewing these indicators, reports of incidents, accidents and other events
relative to safety should be discussed by the committee. From these data sources, the
committee should determine the root causes of adverse events and develop
recommendations to affect change designed to reduce the likelihood of reoccurrence.
These reports could and should come from each of The Joint Commission’s seven
disciplines of the Environment of Care. Incident reports should be reported during the
portion of the meeting at which each of the disciplines is discussed.
Root Cause Analysis
Reporting statistics to the committee is only the start of the process. Unfortunately, this
is where many committees stop. These issues require discussion to determine the root
cause of the problems identified. The Root Cause Analysis should be applied here in
simple or more complex form as appropriate for situation.
The RCA process does not have to be applied in a formal, form-based format, (although
it may help) but the concept of getting to the bottom of the issue and addressing the
underlying cause is essential to creating improvement. Many Safety Committees report
statistics of one kind or another and then conclude “no trends identified”. This will be
true in some cases, but should be the exception rather than the rule.
While some incidents may be declared flukes, most are repetitive and should point to a
need for change. The underlying cause of the adverse event must be identified and
solutions developed to prevent these undesirable events from happening again.
An in-depth discussion of the RCA process would take a paper unto itself, but it can be
summarized as follows:
A Root Cause Analysis (RCA) is a structured evaluation process that identifies the basic
cause of an adverse event and the actions required to prevent a recurrence. It should ask
first what happened, how did it happen and finally why did it happen. After that, the
RCA should identify how recurrence can be prevented. This becomes the
recommendation of the committee and action plans to implement these recommendations
must follow.
Effective Communications
Minutes
Minutes should provide an accurate summary of the issues, discussion and most
importantly, conclusions, recommendations and planned actions of the committee or its
delegates. They can be columnar or narrative, but should clearly indicate the issue(s) at
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
hand, what the group concluded was the cause, what actions are to be taken, by whom
and when. These identified opportunities for improvement are then tracked to
completion (as Old Business for future meetings). When an action has been completed, it
should be so noted in the next meeting’s minutes as “closed”. A minutes template is
included in the attachments.
Action Plans and Reminders
The Safety Committee will make recommendations, but members or other delegates will
have to carry these out. Tracking the completion of these planned actions is an essential
step in assuring an effective safety team. Reminders should be sent by the Safety
Management function (Safety Officer or Committee Chair) as we are all human and all
have full-time jobs in addition to our roles on the Safety Committee and may forget to
follow through. These reminders can be emailed every two weeks until feedback
indicating completion is received.
Time can be lost by not incorporating this process as the only check on completion of
planned actions my be in the next meeting, two months later. Recommended
improvements can only have an impact when they have been fully put into place in the
organization.
Leadership Report
The Leadership Report should focus on areas of interest to the organization’s leadership
including action items, educational needs and reports of completed actions. In this
communication, a summary of the identified issues and the actions recommended for
improvement should be clearly identified. The Leadership Report should include a
request for response from the Governing Body to encourage their involvement in and
dialogue with the committee. A template for this report is in the attachments.
Measuring the Impact
Measuring change in the organization is one of the more challenging things to do well.
The development of performance indicators that have real meaning is not something that
most of us learned in the course of our careers or through formal education. Performance
Indicators must be quantifiable and provide insight into the effectiveness of the
recommendations promulgated by the committee. Performance indicators should be used
to show improvement, or a lack thereof, as a result of the recommendations and actions
of the Safety Committee.
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
The table above provides some suggestions for consideration. There are many more
possible monitors such as these. The key is that they are measurable and provide an
indication of progress or point out need for alternative actions.
Effective Use of the Annual Evaluation Process
The annual evaluation of the Safety Management program is vital to the assessment and
maintenance of an effective Safety Program. One suggested practice for committees that
meet bi-monthly is to hold one extra meeting per year, preferably in January, for the sole
purpose of conducting the annual evaluations. In the annual evaluations, the committee
should first determine how well the goals that it established for itself the prior year were
met. This can be done by a review of the Performance Indicators from the prior year and
related incident report trends to determine if progress was made.
Once this has been done, the committee can then assess the need to continue work in this
area or, if it appears as though the problems have been adequately resolved, the group
should consider replacing this goal, and its related indicator(s) with a new goal and
related indicator(s). This process should be applied to each of the Management Plans for
the Environment of Care. The outcome of this process should be a clear set of goals for
the committee for the new year with appropriate measurement in place in the form of
Performance Indicators.
Conclusion
An effective Safety Committee is engaged in a process of continuous quality
improvement in safety. Their scope impacts all aspects of safety in the organization.
Active involvement brings about positive change and it is that positive change that, in
turn, promotes and rewards involvement. A bit of structure and follow through go a long
way in helping to assure that the efforts of the Safety Committee result in a measurable
impact on the level of safety in the organization.
Attachments:
Sample Safety Committee Agenda
Sample Report to Leadership
Sample Action Plan & Reminder
Sample Safety Committee Minutes
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
PRINT
SEARCH
PREVIOUS VIEW
MAIN MENU
SAMPLE MEDICAL CENTER
SAFETY COMMITTEE
DATE
AGENDA
1. Call to Order/Roll Call
2. Safety Committee Education Presentation
3. Review and Approval of previous Meeting Minutes
4. Main Committee Old Business – (option – see subcommittee reports)
5. Subcommittee Reports
A.
Safety Management
1.
Unfinished Business
a. none
2.
Safety Management Program Report
a.
Performance Standards YTD
c.
Patient/Visitor Incidents
d.
Employee Health Report
1.
Employee Injuries
2.
Employee Exposure
e.
Product Recalls and Safety Notices
f.
Hazard Surveillance
B.
Security Management
1.
Unfinished Business
a.
2.
Security Management Program
a.
Performance Standards YTD
b.
Security Incident Trending Report
C.
Hazardous Materials Management and Waste Management
1.
Unfinished Business
2.
Hazardous Materials Program
a. Review of Performance Standards YTD
b. Radiation Safety Committee Report
c. Laser Safety Report
3.
Waste Management Issues
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
D.
Emergency Preparedness
1.
Unfinished Business
a.
2.
Emergency Preparedness Program
a.
Review of Performance Standards YTD
3. Revision of Hazard Vulnerability Assessment
E.
Fire Prevention and Life Safety Management
1.
2.
MAIN MENU
Unfinished Business
Fire Prevention and Life Safety Management Program
a.
Review of Performance Standards YTD
1. Staff Performance on Fire Drills
2. BMP Compliance Levels
b.
Statement Of Conditions Update
F.
Medical Equipment Management
1.
Unfinished Business
a.
Could Not Locate list.
2.
Medical Equipment Management Program Report
a.
Review of Performance Standards YTD
b.
Equipment Incidents
c.
Equipment Recalls and Safety Notices
G.
Utilities Management
1.
Utilities Management Program Report
a. Performance Standards YTD
b. Utility Incidents Report
c. IAQ Investigation
6.
7.
Main Committee New Business a.
Policy Review Packet
The following are presented to committee for review and comment
8.
Date/Time of Next Meeting:
9.
Adjournment
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
PRINT
SEARCH
PREVIOUS VIEW
MAIN MENU
SAMPLE MEDICAL CENTER
SAFETY COMMITTEE
REPORT TO LEADERSHIP
NAME, Safety Committee Chairperson – DATE
Safety Management Plan
Synopsis of most important issues identified including conclusion, recommendation and
time frame.
Do not list all issues or narrative of discussions – work at a high level but be informative.
Security Management Plan
Emergency Preparedness Management Plan
Hazardous Material Management Plan
Life Safety Management Plan
Medical Equipment Management Plan
Utility Systems Management Plan
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
This page intentionally left blank. (section break)
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
<
>
SEARCH
PRINT
PREVIOUS VIEW
MAIN MENU
© 2006-2008 Tom Zahorsky, CHFM, CHSP
QUIT
>
<
SEARCH
PRINT
Sample Medical Center
Safety Committee Action Items
Act
2day
Topic
Topic from Safety
Committee Minutes
MAIN MENU
QUIT
Date:
Responsible Status
Person
assigned
PREVIOUS VIEW
Listed
Target Completed
Comments
Date
Open, Date
To be
Actual
Supplementary information, progress
Closed Identified completed Completion notes
>
<
TOPIC
PRINT
SEARCH
DISCUSSION
PREVIOUS VIEW
QUIT
MAIN MENU
RECOMMENDATION/ACTION
FOLLOW-UP
SAMPLE MEDICAL CENTER
Minutes of the Safety Committee Meeting
Meeting Date
PRIVILEGED AND CONFIDENTIAL
Standard Hospital confidentiality statement here
1. Call to Order - A regular meeting of the Safety Committee was called to order this date, at (time of meeting) in (location of meeting) at
Sample Medical Center, with the following:
Members Absent:
Members Present:
Guests:
- Safety Officer – Chair
- Chief Operating Officer
- Chief Nursing Officer
- Education Director
- E.D./Emergency Prep
- Bio-Med Lead
– Human Resources
– Plant Operations - Utilities
– Cardio/Pulmonary/Lab
– Materials Management
– Risk Management
- Employee Health Nurse
TOPIC
Guest speakers
Invited attendees for special focuses or
investigations
DISCUSSION
– Radiation Oncology
RECOMMENDATION/ACTION
FOLLOW-UP
2. Education
Presentation
Subject of educational presentation
For Information only
None required
3.
Review of Minutes
The minutes of the meeting of (date of last
meeting) were reviewed.
The minutes were approved as written.
None
4.
Old Business
Items not closed at last meeting that are not
addressed in the seven disciplines below.
Confidential and privileged pursuant to the State Health & Safety Codes Sections
Sample Medical Center Safety Meeting
Meeting Date Page x
>
<
TOPIC
PRINT
SEARCH
DISCUSSION
PREVIOUS VIEW
QUIT
MAIN MENU
RECOMMENDATION/ACTION
FOLLOW-UP
5. EOC Discipline or
Subcommittee Reports
A. Safety Management
1. Unfinished Business
a. Any items that were not closed at the last
meeting.
b.
Note action plan here along with person
responsible and target date for completion or
next major milestone.
For completed items, note that they were
completed and when.
Safety Management
Performance standards
Patient/Visitor
Incidents
Employee Injuries and
Illnesses
Product Recall and
Safety Notices.
Reports and investigation of incidents related
to patient and employee safety.
Discuss the performance indicators for Safety
Management and how they show progress
towards goals established by the committee for
each area.
.
Develop action plans for improvement and/or
continued activity for established improvement
programs. Assign responsibility and set target
dates
Place on agenda for next
meeting for follow up as
Unfinished Business until
“closed”.
For completed items simply
note “closed”
Report on implementation of
action plans or obstacles
encountered at next meeting.
Discussion here focuses on Product recalls and
notices.
Hazard Surveillance
Report and evaluate findings from Hazard
Surveillance activities
B. Security Management
1. Unfinished Business
a. Any items that were not closed at the last
meeting.
Note action plan here along with person
responsible and target date for completion or
next major milestone.
For completed items, note that they were
completed and when.
Confidential and privileged pursuant to the State Health & Safety Codes Sections
Sample Medical Center Safety Meeting
Meeting Date Page x
Place on agenda for next
meeting for follow up as
Unfinished Business until
“closed”.
For completed items simply
note “closed”
>
<
TOPIC
PRINT
SEARCH
DISCUSSION
Discuss the performance indicators for
Security
3. Security Incidents
Reports and investigations of Security
incidents
The format shown for Safety Management is
applied for each of these areas.
E. Fire Prevention and
Life Safety Management
1. Unfinished Business
a.
2. Performance
Indicators
3. Fire Drills
4. SOC Update
Confidential and privileged pursuant to the State Health & Safety Codes Sections
Sample Medical Center Safety Meeting
Meeting Date Page x
QUIT
MAIN MENU
RECOMMENDATION/ACTION
2. Performance
Standards
C. Hazardous Materials
and Waste Management
1. Unfinished Business
a.
Hazardous Materials and
Waste Management
Program
2. Performance Standards
3. Radiation Safety
4. Laser Safety
5. Waste Issues
D. Emergency
Management
1. Unfinished Business
2. Performance
Standards
3. Hazard Vulnerability
Analysis
PREVIOUS VIEW
FOLLOW-UP
>
<
TOPIC
PRINT
SEARCH
DISCUSSION
PREVIOUS VIEW
QUIT
MAIN MENU
RECOMMENDATION/ACTION
FOLLOW-UP
F. Medical Equipment
Management
1. Unfinished Business
a.
2. Performance
Indicators
.
3. Equipment Incidents
4. Equipment recalls and
safety notices
G. Utilities
Management
1. Performance
Monitoring for
Utilities Management
2. Utility Incidents
3. IAQ Investigations
No further action required.
8. Other Business
Any new items brought to committee not
previously discussed.
9. Policy Review Packet
Note all policies reviewed by committee
Date/Time of Next
Meeting
Note date and time of next meeting
Adjournment
Note time of adjournment.
Note actions such as approval or
recommendations for policy updates, new
policies needed.
_____________________________________
Confidential and privileged pursuant to the State Health & Safety Codes Sections
Sample Medical Center Safety Meeting
Meeting Date Page x
Closed or Old Business for next
meeting.
>
<
TOPIC
SEARCH
DISCUSSION
PRINT
PREVIOUS VIEW
RECOMMENDATION/ACTION
Signature of Safety Committee Chairperson
Confidential and privileged pursuant to the State Health & Safety Codes Sections
Sample Medical Center Safety Meeting
Meeting Date Page x
QUIT
MAIN MENU
FOLLOW-UP
<
>
SEARCH
PRINT
Welcome to
Managing an
Effective Safety Committee
45th Annual Conference & Technical Exhibition
Presenters
• Thomas A Zahorsky, CHFM, CHSP
– VP Business Development
– Facilities Technology
gy Group,
p, Austin,, TX
• William A Johnson, CHFM
– Director of Facilities Management
– St. Luke’s Baptist Hospital, San Antonio, TX
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
Problem Identification
• Safety Committee
Inspections
• Incident reports
• Patient complaints/concerns
• Patient satisfaction reports
• Employee satisfaction
reports
• Employee injury rate
• Medical staff
complaints/concerns
• External reviews (TJC,
DSHS)
45th Annual Conference & Technical Exhibition
45th Annual Conference & Technical Exhibition
A Common View
• Often described as….
“The unwilling lead by the
unqualified to do the unnecessary
for the ungrateful”.
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
The “Typical” Safety Committee
•
•
•
•
•
•
No formal Safety training or education
Unclear goals and objectives
Misunderstood process
Meets because they are required to
Focused on satisfying “requirements”
A large group of people
45th Annual Conference & Technical Exhibition
The Hospital
Safety Committee
How many of you are “satisfied”
satisfied
with the manner in which your
Safety Committee functions?
45th Annual Conference & Technical Exhibition
The Hospital Safety Committee
• Does the committee know the strengths
and weaknesses of the safety program?
• Does the committee collect and utilize
data in a meaningful way?
• Does the committee provide
recommendations for improvements in
safety?
• Does the committee follow through?
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
The Hospital Safety Committee
• Does the committee have an impact on the
level of safety in the organization through
the management of performance
improvement activities?
• Does the committee utilize meaningful
performance indicators to monitor their
impact on safety in the organization?
45th Annual Conference & Technical Exhibition
The Hospital
Safety Committee
What is an “Effective
Effective Safety
Committee”?
45th Annual Conference & Technical Exhibition
The Hospital
Safety Committee
An effective Safety Committee is one that has a
significant impact on safety in the
organization and knows what that impact is
through measured performance indicators.
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
Essentials
• Leadership Involvement and Administrative
Support
• Engaged membership
• Effective Management of Information
• A Structured Meeting Process
• A Problem Identification and Evaluation Process
• Recommendations and Actions
• Effective Communications
• Effective Means of Measuring Improvement
• Effective Use of the Annual Evaluation Process
45th Annual Conference & Technical Exhibition
Leadership Involvement
• LD.4.70 – Leadership measures and assesses
safety improvement activities
• LD.4.60 – Leadership assures patient safety
• LD.3.60 – Leadership assures effective
communications
45th Annual Conference & Technical Exhibition
Administrative Support
• Chair appointed annually in writing by CEO
• Membership chosen by Chair, appointed by
CEO annually
• Stated commitment to safety
• Participation
– Meeting attendance
– Support For Recommendations
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
Membership
•
•
•
•
Administration
Nursing Services
Ancillary Services
Departments with Safety Issues
– EVS, Food Service, ICU, Lab
• Support Services
45th Annual Conference & Technical Exhibition
Membership
•
•
•
•
•
CNO or COO
ICU or other Nursing Director
Emergency Department Staff
gy Director
Lab Director,, Radiology
Departments with Safety Issues
– EVS, Food Service, ICU, Lab
• Security, Engineering, Bio-Med
• Purchasing (Materials Mgt.)
45th Annual Conference & Technical Exhibition
Information Collection and
Evaluation System (ICES)
• Effective Information Gathering And
Evaluation Process
–
–
–
–
–
Performance indicator data for all 7 areas
Incident reports/summaries
Newsletters, periodicals – relevant updates
Employee suggestions
Other information relative to safety
45th Annual Conference & Technical Exhibition
PRINT
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
PRINT
SEARCH
Sample Medical Center
Information Collection and Evaluation System
(ICES)
Adminstration
and Dept. Dirs
Staff Updates
Action Plans
Safety Committee
Chair Report to
Leadership
Committee
Recomendations
Others Assigned
Action Plans
Feedback on
Implementation
Safety Committee
Collects and
Evaluates Data
Safety Management
Patient Safety
Employee Safety
Hazard Surviellance
Product Recalls
Emergency
Management
HVA, Plans
Drills, Events, Critiques
Equipment & Supplies
Security Management
Security Incidents
Performance Indicators
Security Drills
Hazmat & Waste
Management
Spills/Incidents
MSDS Maintenance
Right To Know
Life Safety
Management
Fire Drills
BMP
Fire Safety Equipment
Medical Equipment
Management
Bio-Medical
Diagnositc Imaging
Utility Management
Utility Incidents
Performance Indicators
Infection Control
Education
Staff Knowledge
and Training in All
Areas
45th Annual Conference & Technical Exhibition
Structured Meeting Process
• Standardized Agenda
• Stick to the Agenda
• Prevent the “Hi-Jacked Meeting”
•
•
•
•
•
Include Committee Education
Monitor all Old Business
Monitor all Performance Indicators
Incident Reports for all Areas
Save “New Business” until last
45th Annual Conference & Technical Exhibition
Problem Identification
• Recognize when the sentence starts with
“we need to…” that is not problem
identification
• We often tend to start at the point of
offering solutions without taking the time
to state the problem
• Stating the problem is the first step
• Only then can all committee members give
thought to what caused the problem
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
Problem Evaluation
• Reporting statistics is only the starting
point
• Analysis must work to determine what
happened,
pp
, why,
y, ((when,, where and who
may also be important)
• Most significantly, how can a recurrence
by prevented?
45th Annual Conference & Technical Exhibition
Problem Evaluation to
Recommendation
How can a
recurrence
be
prevented?
45th Annual Conference & Technical Exhibition
Recommendations and Actions
• Once ICES information is analyzed,
committee makes recommendations for
improvement
• Formal,, informal ((formal = PI))
• Recommendations include what, who and
when
• How will success be measured?
• Track to completion – hold accountable
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
Effective Communications
•
•
•
•
Minutes
Action Plans
N i /R i d
Notices/Reminders
Reports to Leadership
45th Annual Conference & Technical Exhibition
Meeting Minutes
• Capture Topic, Conclusions,
Recommendations and Planned Actions
• Assure follow up,
p, follow through
g
• Use “Old Business” to track to completion
• Use P.I. to track formal improvement
activities
• Do not drop incomplete items
45th Annual Conference & Technical Exhibition
Action Plans - Notices
•
•
•
•
•
•
In addition to minutes
Assure awareness of planned actions
Use as Reminders
Offer assistance but don’t take ownership
Encourage Response or Require response
Administrative Support
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
Report to Leadership
•
•
•
•
Governing Board
Senior Management
Department Directors
Summary of minutes – significant issues
only
• Spare the details – inform and involve
• Speak to the importance to them
45th Annual Conference & Technical Exhibition
Accountability for Action
•
•
•
•
•
Essential to the stimulus of change
Other priorities will distract
Reminders notices,
Reminders,
notices awareness
Administrative Support
Encourage, be positive, show value of
actions
• Be firm
45th Annual Conference & Technical Exhibition
Measured Results
• Did the actions recommended by
committee have the desired impact?
• How is this measured?
• Could be as simple as yes/no
• Could be a trend
• Could evolve into a Performance Indicator
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
>
SEARCH
PRINT
Performance Indicators
• Performance indicators are meaningful
when they measure progress towards
meeting committee established goals
• One for each of the seven disciplines of
the EOC or
• More than one in a particularly
problematic area
45th Annual Conference & Technical Exhibition
Performance Indica
ators for the EOC
<
Safety Management
Monitor the knowledge of employees in the safety components of annual re-training. Test
scores from each of the EOC Categories are at least 95% taken by random sampling.
¾ Safety Management
¾ Employee Safety Management
¾ Security Management
¾ Emergency Management
¾ Hazardous Materials and Waste Management
¾ Life Safety Management
¾ Medical Equipment Management
¾ Utilities Management
National Patient Safety Goal Compliance Rate
Inpatient Fall Rate (falls/1000 patient days)
Employee Safety – Lost Time Injury Rate is Below State Average for SIC Code
Employee Safety – Needle stick or other injury rate below prior year (per 100,000 worked hours)
Hazard Surveillance – percent of probes found to be in compliance
Product Recalls – percent of recalls and notices responded to by deadlines
Security Management
Security Incidents per month by type
Security - % of CCTV system operational monthly
Security – staff scores on security drills
Security – response time to events of different types
Security – number of incidents of different types compared to year prior
Emergency Management
Emergency Preparedness scored staff performance on drills
Percent of HRSA Grant Funded Supplies Locatable
Percent of Emergency Contacts Valid During Random Test Calls (after hours)
Hazardous Materials and Waste Management
Hazardous Materials % accuracy of MSDS books random sample
Hazardous Materials & Waste – lbs. Infectious waste/patient day prior year comparison
Fire Prevention and Life Safety
Life Safety – staff score at least 95% on fire drill performance
Life Safety – all staff participate each year
Life Safety – BMP compliance rates > 95%
Medical Equipment Management
Medical Equipment Management – percent PM completed monthly
Medical Equipment Management – percent repairs completed (m)
th
Medical Equipment Management – average turn around time
Medical Equipment Management – User Error Rate as % of reported equip. failures
45 Annual Conference & Technical Exhibition
Using the Annual Evaluation
• Evaluate last year’s performance
indicators
• Determine actual effectiveness of
programs, recommendations and actions
• Compared to established goals
• Determine need to continue
• Evaluate new developments
• Recommend goals for new year
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT
<
>
SEARCH
PRINT
Conclusion
• A committee that has a real impact on the
organization and is able to measure that
impact provides an environment that
stimulates involvement
• Having structure in the meeting process
and follow through on actions contributes
to having that impact
• Involvement then becomes its own reward
45th Annual Conference & Technical Exhibition
Questions and Answers
• Contact information:
• Thomas A Zahorsky, CHFM, CHSP
– VP Business Development
– Facilities Technology Group, Austin, TX
– [email protected] 281
281-362-1686
362 1686
• William A Johnson, CHFM
– Director of Facilities Management
– St. Luke’s Baptist Hospital, San Antonio, TX
– [email protected] 210-297-5692
45th Annual Conference & Technical Exhibition
PREVIOUS VIEW
MAIN MENU
QUIT